Same-Day Discharge for TJR: Clinical Guidelines and Caveats

Value-based reimbursement and alternative payment models are putting increased pressure on the profitability of joint replacement procedures. Although same-day discharge is not a common part of these programs yet, according to James D. Slover, MD, the new payment paradigm will favor ambulatory surgery in the future.

At the 2017 Interdisciplinary Conference on Orthopedic Value-Based Care, Dr. Slover detailed best practices for outpatient joint replacements, which are expected to increase by 200% in the next decade (www.sg2.com/?health-care-intelligence-blog/?2016/?10/?prepared-shift-outpatient-total-knee-replacement/?).

“The transition to more outpatient procedures won’t happen overnight,” said Dr. Slover, an orthopedic surgeon at NYU Langone Medical Center, in New York City.

“It will require careful preparation—investing time to develop protocols and processes involving all members of the care team—to ensure a safe experience for patients. However, if we do this safely and efficiently while preserving quality, we can maintain a positive margin in this alternative payment environment.”

As Dr. Slover reported, since 2014, several hundred same-day total hip arthroplasties have been performed at NYU Langone Medical Center, and in early 2016, the center began same-day discharge for total knee and total shoulder arthroplasties, as well.

“We pursued this strategy cautiously and gradually, starting with select physician leaders who had reliably demonstrated discharge of patients in one day,” he explained. “Physicians need to be very involved in the process because it requires a lot of work outside the hospital beforehand.”

The biggest component, however, may be the patients themselves, who must be healthy and motivated for same-day surgery to be successful. As Dr. Slover indicated, patients must meet the following medical inclusion criteria to be considered:

no active cardiac arrhythmia;

no chronic anticoagulation medications;

no moderate to severe obstructive sleep apnea;

no medical comorbidities, such as chronic obstructive pulmonary disease or cardiac disease;

a hemoglobin level of at least 12 g/dL; and

a body mass index less than 40 kg/m2.

“In addition to these physiological requirements,” Dr. Slover said, “patients must be in full agreement. You’re not going to do well trying to convince them to do this.”

Nevertheless, for patients who do attempt same-day discharge, reinforcing expectations is critical.

“Patients need to know that this is a normal thing,” he added. “They need to be reminded that it’s not unsafe or experimental, and that appropriate support mechanisms have been put in place to do this successfully.”

Preoperative Protocol

Same-day discharge patients require a “coach,” a care companion willing to be with them on the day of surgery and spend the first night with them at home. In addition, both patient and coach must attend a preoperative education, or “prehab,” session, in which care management, pain control, deep vein thrombosis prophylaxis and assistive device training are discussed.

“Our pre-op protocol has been a major part of our success,” Dr. Slover said. “Patients need to recognize that arrangements have been made and that they will receive the care they need. The first time they’re hearing these instructions should not be on the afternoon after surgery.”

For patients with a history of motion sickness, he added, use of a 1.5-mg scopolamine patch should be considered.

“We’re constantly trying to tweak this protocol, but the important message is that partners are needed across the whole continuum of care,” Dr. Slover said. “You’re not going to just insert this into the system as normal. You have to find champions in surgery, anesthesia and nursing, and work together to develop this pathway and protocol.”

During surgery, Dr. Slover and his colleagues rely on a short-acting spinal anesthetic—bupivacaine and chloroprocaine—and avoid use of a narcotic in a spinal block.

“These can’t be complex procedures,” he explained. “It’s important to pick patients where surgery is going to go well and where surgical trauma can be relatively minimal.”

Finally, in the postoperative period, Dr. Slover advised limiting narcotics and use of patient-controlled analgesia.

“We want patients to be comfortable and on a regimen that they’re going to use at home so that they know they can control their pain adequately,” he said.

This phase includes 1 g of acetaminophen by mouth; 5 mg of oxycodone by mouth for discomfort at a pain rating scale of 1 to 3; and 10 mg of oxycodone for pain rated 4 to 10.

“Go slow, pick the right patients, educate them, verify that infrastructure is in place, and make sure that all team members are dedicated to the process,” Dr. Slover concluded.

“Anesthesiologists are an integral part of the program,” Dr. Marshall said. “We were very happy to get on board and work to make sure that we developed an efficient and safe protocol that would serve the needs of the patient, the surgeon and the [anesthesiologist] as well.”

“We’ve come a long way in the last two years, working with the surgeons,” Dr. Nazemzadeh said. “Now almost every total joint is a candidate for same-day discharge.”

“At some point, like the four-minute mile, you reach a point where progress is only incremental,” Dr. Marshall added, “but we always think there’s room for optimization.”

Testimonials

“As Director of Surgical Services Departments there has been considerable changes have occurred in my department and Anesthesia Experts has always risen to meet our demands of our facility. They have been very pro-active in meeting the increase volumes allowing us to keep our surgeons and patients very satisfied with our services.”

AR BSN 346 beds AL

“Before AE took over the anesthesia department was described by the surgeons as the worst in the history of our hospital. The prior management company was having a cancelled surgery per day. I am happy to report there has not been one since they have taken over the department. Additionally we have seen a 905 reduction if requested preop
lab tests. The anesthesia department is now the very best hospital department in our entire facility.”

DS CEO 272 beds MS

“Anesthesia Experts has provided consistent anesthesia providers who display a high degree of integrity, responsibility and professionalism. They have become a more valuable part of our facility and community.”

LR CEO 150 beds TX

“Even though they are physically located 1000 miles away Anesthesia Experts just does not provide great anesthesia coverage they personally engage surgeons to increase their business. Last year my surgical volume rose by 24% and we are currently 50% ahead of last year and all of that growth is organic.”

JE FACHE CEO AL 92 bed hospital

“Anesthesia Experts is more responsive than anyone I have dealt with. They are available by phone whenever needed and will be on site for any need or request and has been on site to address issues before we can make the request.”

SW CEO 25 beds NM

“While problems are extremely rare when they do occur Anesthesia Experts quickly and professionally implements a solution. Our surgical volume has grown over 100 cases per month and now our GI docs want to perform all of their endoscopies in our hospital instead of their GI lab that they own!”

SP CEO 346 beds AL

“Our anesthesia department was a thorn in my side that kept me awake at night. Anesthesia Experts swept in and brought order to our mess and our department was quickly redirected.”